I hereby authorize Dr. Gregory Wheeler to use telemedicine (telephone, email, text, and fax) in the course of my diagnosis and treatment. I understand that telemedicine involves the communication of my medical information orally via phone, internet or other telemedical devices to myself, as well as, potentially to other physicians and other health care practitioners located in other parts of the state or outside of the state.
I understand that I have all the following rights with respect to telemedicine:
Patient Choice of Care. I have the right to withhold or withdraw my consent to telemedicine at any time without affecting my right to future care or treatment and without risking the loss of my health coverage.
Access to Information. I have the right to inspect all medical information transmitted during a telemedicine consultation; and may receive copies of this information for a reasonable fee.
Confidentiality. I understand that the laws which protect the confidentiality of medical information apply to telemedicine; and that no information or images from the telemedicine interaction which identify me will be disclosed to researchers or other entities without my consent.
Potential Risks. I understand that there are risks from telemedicine, including the possibility, despite reasonable and appropriate efforts, that: the transmission of medical information could be disrupted or distorted by technical failures in transmission; the transmission of medical information could be interrupted by unauthorized persons. In addition, I understand that telemedical examinations or care may not be as complete as face-to-face examinations or care and that telemedicine does not negate or minimize the risks that may be inherent in a consultation.
Finally, I understand that it is impossible to list every possible risk, that my condition may not be cured or improved, and sometimes, may get worse.